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INDIANA UNIVERSITY /
CENTER FOR HEALTH POLICY
County Readiness Survey
You are invited to participate in a research study to assess your county’s readiness to implement substance abuse prevention programs. You were selected as a possible subject because of your professional interest and commitment to prevent and reduce alcohol, tobacco, and illicit drug use.
The study is part of the State Prevention Framework State Incentive Grant (SPF SIG). The SPF SIG is a five-year federal grant designed to help grantees build a solid foundation for delivering and sustaining effective substance abuse and/or mental health services. It is awarded to individual states by the Center for Substance Abuse Prevention (CSAP), a division of the Substance Abuse and Mental Health Services Administration (SAMHSA). The purpose of the grant is to prevent the onset and reduce the progression of substance abuse, including underage drinking, reduce substance abuse related problems in communities; and assess and build capacity at the state/tribal and community levels. The county readiness assessment is being conducted by the Center for Health Policy, Indiana University School of Public and Environmental Affairs. The data collected in this survey will be made available, in an anonymous format, to Indiana counties to help them identify their current state of readiness, which may assist them in the application for SPF SIG grants.
You must be at least 18 years of age to participate in this survey. The survey will take approximately 15 minutes to complete and does not pose any foreseeable risks or discomforts to you.
Participation in this survey is entirely voluntary, i.e., you don’t have to partake; you don’t have to answer any questions you consider inappropriate; and you may stop the survey at any point. The survey is completely confidential.
By completing this questionnaire, you verify that:
* You understand the purpose of this survey;
* You voluntarily agree to participate; and
* You are at least eighteen (18) years of age.
If you have any questions about this survey and your rights, please contact:
Eric Wright, Ph.D.
(317) 261-3031

Marion Greene, MPH
(317) 261-3029

If you agree to participate, please initial here: ______

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Please enter the access code that was provided in your email message.

Access Code:

COMMUNITY

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Name of your county:

EXISTING PREVENTION EFFORTS

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List the substance abuse prevention programs, activities, services, and policies that are in place in your county, who they serve (for example, individuals belonging to a certain age group, race, religion/church, geographic area, etc.), and their funding source.
Prevention Effort Name: ______
Target Population: ______
Source of Funding: ______
Prevention Effort Name: ______
Target Population: ______
Source of Funding: ______
Prevention Effort Name: ______
Target Population: ______
Source of Funding: ______
Prevention Effort Name: ______
Target Population: ______
Source of Funding: ______
Prevention Effort Name: ______
Target Population: ______
Source of Funding: ______
Prevention Effort Name: ______
Target Population: ______
Source of Funding: ______
Prevention Effort Name: ______
Target Population: ______
Source of Funding: ______
Prevention Effort Name: ______
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Source of Funding: ______
Prevention Effort Name: ______
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Source of Funding: ______
Prevention Effort Name: ______
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Prevention Effort Name: ______
Target Population: ______
Source of Funding: ______

COMMUNITY KNOWLEDGE OF PREVENTION EFFORTS

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On a scale of 1 to 10, how aware are people in your county of substance abuse prevention efforts, with 1 being 'not aware' and 10 being 'very aware'?
Not Aware /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10 / Very Aware
Is there a need to expand the substance abuse prevention efforts in your county?
Yes / / No / / Don't Know/Not Sure /
Is there planning for additional substance abuse prevention services/programs going on in your county?
Yes / / No / / Don't Know/Not Sure /

LEADERSHIP

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On a scale of 1 to 10, how much of a concern is substance abuse prevention to the leadership in your county, with 1 being 'no concern' and 10 being 'very large concern'?
No Concern /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10 / Very Large Concern
Would the leadership in your county support additional substance abuse prevention efforts?
Yes / / No / / Don't Know/Not Sure /
Do you know who the substance abuse prevention leaders are in your county?
Yes / / No / / Don't Know/Not Sure /

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LEADERSHIP

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List the top three substance abuse prevention leaders in your county and to which organization or agency they belong.

Name:

Agency/Organization:

Name:

Agency/Organization:

Name:

Agency/Organization:

COMMUNITY CLIMATE

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Is there ever a time or circumstance in which members of your county think that substance abuse should be tolerated?
Yes / / No / / Don't Know/Not Sure /
On a scale from 1 to 10, how much of a concern is substance abuse in your county, with 1 being 'no concern' and 10 being 'very large concern'?
No Concern /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10 / Very Large Concern
On a scale from 1 to 10, what is your county's attitude about substance abuse prevention, with 1 being 'not important' and 10 being 'very important'?
Not Important /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10 / Very Important
On a scale from 1 to 10, how important is it to your county to prevent substance abuse among youth, with 1 being 'not important' and 10 being 'very important'?
Not Important /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10 / Very Important

COMMUNITY KNOWLEDGE OF SUBSTANCE ABUSE

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On a scale from 1 to 10, how knowledgeable are members of your county about substance abuse (such as statistics, symptoms, consequences, etc.) with 1 being 'not knowledgeable and 10 being 'very knowledgeable'?
Not Knowledgeable /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10 / Very Knowledgeable
On a scale from 1 to 10, how knowledgeable are members of your county about risk factors leading to substance abuse, with 1 being 'not knowledgeable' and 10 being 'very knowledgeable'?
Not Knowledgeable /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10 / Very Knowledgeable
Is local data on substance abuse available in your county?
Yes / / No / / Don't Know/Not Sure /

COMMUNITY KNOWLEDGE OF SUBSTANCE ABUSE

Is enough local data on substance abuse available in your county?
Yes / / No / / Don't Know/Not Sure /
In which area is more local substance abuse data needed in your county?

On a scale from 1 to 10, how much do the local media contribute to inform and educate your county on substance abuse related issues, with 1 being 'no contribution' and 10 being 'extensive contribution'?
No Contribution /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10 / Extensive Contribution

COMMUNITY KNOWLEDGE OF SUBSTANCE ABUSE

On a scale from 1 to 10, rate the following substances on the number of problems they cause in your county, with 1 being 'causing no problems' and 10 being 'causing many problems'.
Alcohol /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10
Cocaine/Crack /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10
Hallucinogens /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10
Heroin /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10
Inhalants /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10
Marijuana /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10
Methamphetamine /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10
Prescription Drugs /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10
'Rave Drugs' (e.g., Ecstasy, GHB) /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10
Tobacco /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10

RESOURCES FOR PREVENTION

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On a scale from 1 to 10, what is the level of expertise, training, and/or skill among the substance abuse prevention program staff in your county, with 1 being 'no expertise' and 10 being 'extensive expertise'?
No Expertise /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10 / Extensive Expertise
On a scale from 1 to 10, how supportive are the local businesses in your county of substance abuse prevention efforts (such as volunteering time, making financial donations, providing space, etc.), with 1 being 'not supportive' and 10 being 'very supportive'?
Not Supportive /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10 / Very Supportive
On a scale from 1 to 10, how supportive are the citizens in your county of substance abuse prevention efforts, with 1 being 'not supportive' and 10 being 'very supportive'?
Not Supportive /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10 / Very Supportive
On a scale from 1 to 10, how much collaboration occurs among public and private agencies involved in substance abuse prevention, with 1 being 'no collaboration' and 10 being 'extensive collaboration'?
No Collaboration /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10 / Extensive Collaboration

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DEMOGRAPHICS

Gender:

/ Male / / Female

Age: years

Race/Ethnicity:Educational Background:

/ African American/Black / / Less than high school diploma or GED
/ American Indian / / High school graduate
/ Asian / / Some college/vocational school
/ Caucasian/White / / College degree
/ Hispanic / / Graduate degree
/ Pacific Islander
/ Other

Which of the following categories best describes your occupation?

/ Academia/research
/ Clergy
/ Counseling and social services
/ Criminal justice
/ Education
/ Government leader
/ Law enforcement
/ Medical field
/ Public Health
/ Substance abuse prevention/intervention
/ Other
On a scale from 1 to 10, rate your knowledge of substance abuse prevention efforts in your county, 1 being 'no knowledge' and 10 being 'extensive knowledge.
No Knowledge /
1 /
2 /
3 /
4 /
5 /
6 /
7 /
8 /
9 /
10 / Extensive Knowledge
Do you have any comments regarding substance abuse prevention or this survey?

COMMUNITY CONTACTS

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Do you know any other community leaders or individuals who are knowledgeable about substance abuse prevention we can contact? If so, please list their names, email, addresses, and/or phone numbers.

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Name:

Email:

Address:

City:

State:

Zip Code:

Phone:

Name:

Email:

Address:

City:

State:

Zip Code:

Phone:

Name:

Email:

Address:

City:

State:

Zip Code:

Phone:

CENTER FOR HEALTH POLICY
FINISHED
You have completed the survey. Thank you for helping us get a better picture of the substance abuse prevention efforts in your county. Your responses are vital in improving substance abuse programs and availability in your area.
If you have any questions about this survey and your rights, please contact:
Eric Wright, Ph.D.
(317) 261-3031

Marion Greene, MPH
(317) 261-3029